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°°:..: ° � STATE OF CALIFORNIA i _ STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� : e Yj � p �•t.•Own.w COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY F-1 I NEW PERMIT O 3 RENEWAL PERMITS CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT E & TEMPORARY SITE CLOSURE 5,.3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR GO 41 !< tis ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) �Y/ W /SS-oya- ( -?— CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ✓ BOX CA IQ o CA TO INDICATE IQ CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL—AGENCY Q COUNTY AGENCY =1STATE-AGENCYQ FEDERALJGFNCV DISTRICTSTRICTSTRICiS TYPE OF BUSINESS 0 ( GAS STATION 0 2 DISTRIBUTOR "' IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(Wfiona)) RESERVATION Q 3 FARM Q 4 PROCESSOR S OTHER pR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED NAME / CARE OF ADDRESS INFORMATION Gc�ocl GJY �/ �d/G145�Arrs MAILING OR STREET ADDRESS ✓ butinOiem Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY d / S. Gru .-,7 pl t - Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE SAV (_/c/ .' C.4 4S1 of III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION SLe r>^-P Cr- S MAILING OR STREET ADDRESS ✓ Wa 10 mic u Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4174 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)-IDENTIFY THE MET OD(S) USED ✓ boa biMlcaM Q I SELF-INSURED Q 2 GUARANTEE INSURANCE =4 SURETY BOND IQ 5 LETTEROFCREDR Q S EXEMPTION Q N OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it.= IN. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PH WTED&SIGNATURE) APPLICANT'S TITLE DATE MONTWOAYIYEAR LOCAL AGENCY USE ONLY COUINTTYY# JURISDICTION# FACILITY# (E: LOCATION CODE -OPTIONAL CENSUS TRACT# -OPPONAL SUPVISOR-DISTRIC -OP 770NAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A-5 A 6�